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Vaccination  for  the 
Prevention  of  Smallpox 

By  Dr.  Alvah  H.  Doty 

Medical  Director  of  the  Employees*  BeneBt  Fund  Committee 
of  the  American  Telephone  and  Telegraph  Compcmj, 

The  Western  Union  Telegraph  Company,  and 
The  Western  Electric  Company 


Number  12.  Supplement  to  Western  Electric  News.  Feb.,  1914 


This  is  one  of  a series  of  monthly  bulletins  on  Hygiene^  San- 
itation, and  the  Prevention  of  Disease.  It  is  suggested  that  the 
articles  be  kept  for  reference,  as  in  this  way  a hand-book  on 
the  subject  of  Hygiene  may  be  secured. 


G ! "FT! 


I ) 


Vaccination  for  the 
Prevention  of  Smallpox 


By  DR.  ALVAH  H.  DOTY 


Eef erence  is  constantly  being  made  in  the  public  press  and  other  cur»  • 
rent  literature  to  the  use  of  vaccine,  anti-toxin,  and  serum  in  connection 
with  the  prevention  and  treatment  of  disease.  While  the  terms  are  more 
or  less  familiar  to  all  the  means  by  which  these  agents  are  obtained,  the 
theory  regarding  their  action  and  the  results  that  are  expected  are  not 
clear  in  the  public  mind. 

Vaccination  for  the  prevention  of  Smallpox  is  the  protective  measure 
^of  the  above  group  best  known  and  most  commonly  employed  and  will 
therefore  be  dealt  with  in  this  article.  Similar  preventive  measures  will 
subsequently  be  considered. 

Many  years  before  vaccination  was  thought  of,  a means  of  modifying 
Smallpox  or  rendering  it  mild  known  as  “inoculation”  was  exten- 
sively practiced  in  the  East,  particularly  in  Constantinople.  This  was  in 
active  operation  about  1700  and  a century  later  was  introduced  into 
England.  Inoculation  consisted  in  obtaining  fluid  or  lymph  from  the 
little  vesicles  which  form  during  the  early  stage  of  the  eruption  of  this 
disease  and  introducing  it  under  the  skin  of  those  who  desired  or  were 
forced  to  receive  this  form  of  protection.  While  Smallpox  was  pro- 
duced in  the  one  inoculated,  it  was  usually  of  a very  mild  type,  and  pro- 
tected against  the  danger  of  contracting  the  disease  in  the  regular  way 
with  the  possibility  of  causing  a great  disflgurement  or  a fatal  result.  It 
was  found,  however,  that  although  inoculation  extended  protection  in 
the  way  described,  a person  thus  treated  became  a medium  of  infection 
and  transmitted  Smallpox  to  others,  often  in  its  severest  form,  and  in 
England  its  further  use  was  prohibited  by  an  Act  of  Parliament  in  the 
' early  part  of  the  last  century. 

Inoculation  may  appear  to  us  an  exceedingly  drastic  method  of  pro- 
i tection,  but  it  must  be  remembered  that  at  the  period  it  was  employed  the 

f public  was  almost  helpless  in  preventing  the  ravages  of  Smallpox  and 

were  willing  to  take  advantage  of  almost  any  measure  which  provided 
even  partial  defense  against  it.  There  is  probably  no  subject  the  statis- 
tics of  which  are  more  voluminous  and  more  convincing,  than  those  which 


J 


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UNIVERSITY  OF 
ILLINOIS  LIBRARY 
AT  URBANA  CHAMPAIGN 


relate  to  the  destruction  which  followed  in  the  wake  of  this  disease  before 
vaccination  was  discovered,  for  one-tenth  to  o le-half  of  all  deaths  which 
occurred  were  caused  by  Smallpox,  and  one-third  of  the  number  of  babies 
born  died  from  it  within  a year,  and  many  of  those  who  recovered  were 
either  made  blind  or  otherwise  disfigured.  In  173d  two-thirds  of  the 
entire  population  of  Greenland  died  from  this  disease,  therefore,  it  is  not 
strange  that  the  public  mind  was  constantly  disturbed  regarding  the 
danger  from  this  source. 

During  the  latter  part  of  the  18th  century.  Dr.  Edward  Jenner,  a 
young  English  physician  who  had  given  this  subject  careful  and  exhaus- 
tive study,  had  learned  of  the  tradition  existing  among  employes  of 
dairies  that  those  whose  hands  became  infected  while  milking  cows  having 
a disease  known  as  ‘‘  Cowpox,”  which  caused  an  eruption  about  the  udder 
or  teats  of  the  cow,  were  protected  against  Smallpox.  It  seems  strange 
that  this  alleged  immunity  had  not  before  received  earnest  attention,  bi?t 
the  indifference  of  the  public  to  traditions  and  the  reticence  on  the  part 
of  dairy  owners  to  furnish  information  which  might  unfavorably  affect 
their  business,  may  partly  account  for  this;  however,  it  did  not  escape 
the  careful  observation  of  Jenner  who,  for  almost  thirty  years,  investi- 
gated this  subject  and  then  having  demonstrated  satisfactorily  to  him- 
self the  protective  power  of  the  method  afterwards  known  as  ‘‘vaccina- 
tion,’’ he  presented  to  the  world  a minute  and  extensive  description  of 
his  work  and  his  conclusions  relative  to  this  protective  measure. 

Jenner  did  not  try  to  conceal  his  discovery,  but  freely  discussed  it  and 
invited  aid,  but  for  a long  time  met  with  nothing  but  indifference  and 
discouragement.  Even  Dr.  John  Hunter,  one  of  the  greatest  physicians 
of  his  time  and  under  whose  care  Jenner  studied  as  a favorite  pupil,  was 
at  first  but  little  impressed  with  the  importance  of  vaccination,  although 
he  frequently  referred  to  it  in  his  lectures.  Still  undaunted,  Jenner 
continued  his  investigation  and  on  May  14th,  1796,  was  allowed  to  “vac- 
cinate” a boy  eight  years  Of  age  with  some  lymph  or  fluid  taken  from 
a vesicle  on  the  hand  of  a dairy  maid  who  had  contracted  the  so-called 
“cowpox.”  In  July  of  the  same  year  this  boy  was  inoculated  with 
Smallpox  in  the  manner  already  described  and,  as  Jenner  predicted,  the 
latter  disease  did  not  occur.  Jenner  afterwards  vaccinated  others  with 
similar  successful  results.  The  account  of  his  discovery  soon  became 
known  through  the  world  and  vaccination  spread  with  great  rapidity, 
being  introduced  into  the  United  States  about  1800. 

Jenner  believed  that  the  protective  power  of  “vaccination”  depended 
upon  the  fact  that  the  disease  known  as  “cowpox”  was  really  Smallpox 
in  the  cow,  but  the  infection  in  passing  through  the  system  of  this  animal 
became  greatly  modified  or  changed  in  character,  although  it  afforded 
protection  against  Smallpox  when  introduced  into  the  human  being. 
This  belief  is  still  maintained,  although  the  practical  disappearance  of 
cowpox  has  made  it  impossible  for  the  scientists  of  the  present  time  to 
continue  the  investigation  begun  by  Jenner. 


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It  is  reasonable  to  assume  that  the  hands  of  the  milker  through  cracks 
or  minute  openings  in  the  skin  became  infected  by  contact  with  the  vesi- 
cles on  the  udder  or  teats  of  the  cow  and  that  this  infection  upon  entering 
the  system  provided  protection  against  Smallpox,  the  original  cause  of 
the  disease  in  the  cow.  Jenner  very  properly  argued  that  the  same  result 
would  be  secured,  but  in  a much  more  satisfactory,  effective  and  practical 
manner  if  the  contents  of  these  vesicles  were  obtained  in  a more  scientific 
way,  in  order  that  the  lymph  could  be  conveniently  and  at  any  time  intro- 
duced under  the  skin  of  those  who  were  to  receive  the  benefits  of  this  pro- 
tection. This  was  done  by  opening  the  vesicles  on  the  udder  or  teats  of 
the  cow  and  removing  their  contents  on  various  articles  possibly  of  ivory, 
glass,  or  quills,  etc.,  from  which  it  could  easily  be  transferred  to  a scari- 
fied or  exposed  surface  of  the  skin.  This  was  the  origin  of  vaccination^ 
The  lymph  or  virus,  as  it  is  called,  is  interchangeable  between  the  cow 
and  the  Wman  being,  i.  e.,  the  lymph  taken  from  the  vesicles  on  the  cow 
will  successfully  vaccinate  a human  being,  and  that  removed  from  the 
human  vesicle  can  be  used  for  vaccinating  the  cow,  or  the  virus  may  be 
transferred  directly  from  one  person  to  another.  In  this  way  the  supply 
of  vaccine  matter  may  be  perpetuated.  A fresh  supply  has  been  obtained 
by  inoculating  cows  with  the  lymph  taken  from  the  Smallpox  vesicle.  At 
the  present  day  the  supply  is  maintained  by  vaccinating  young  calves 
with  the  vaccine  matter  from  other  calves  or  from  children.  At  the 
proper  stage  the  lymph  or  fluid  in  the  vesicles  on  the  cleanly  shaven 
abdomen  of  the  calf  is  removed  and  taken  to  the  laboratory,  where  it  is 
examined  to  detect  the  presence  of  contaminating  organisms  and  also 
carefully  tested,  the  latter  is  then  mixed  with  glycerine  or  some  other 
agent  placed  in  small  vials  and  hermetically  sealed  and  is  then  ready 
for  use. 

When  a vaccination  is  successful  or  ‘‘takes”  a very  characteristic 
vesicle  appears  within  a few  days  after  the  operation  at  the  point 
of  introduction  of  the  virus ; this  passes  through  various  stages,  becomes 
dried  and  the  scab  afterwards  drops  off  at  varying  periods,  leaving  a 
characteristic  depression  or  scar  which  to  those  who  are  practically 
familiar  with  its  appearance  indicates  the  success  of  the  vaccination. 

Until  about  twenty  years  ago  vaccination  was  performed  chiefly  by 
what  is  known  as  “arm  to  arm”  vaccination.  This  consisted  in  taking 
lymph  from  the  vaccine  vesicle  on  the  arm  (or  other  part  of  the  body) 
of  a recently  vaccinated  healthy  child  and  immediately  transferring  it 
to  the  scarified  arm  of  the  children  or  adults  brought  together  for  this 
purpose. 

Another  former  method  of  vaccination  consisted  in  collecting  the  scabs* 
from  the  arms  of  children  known  or  believed  to  be  in  good  healthy  con- 
dition, mixing  it  with  glycerine  or  some  other  fluid  and  using  it  for  vac- 
cination. While  these  methods  were  very  successful  it  was  feared  that 
they  constituted  a possible  medium  of  transmitting  diseases  from  one 
person  to  another,  although  the  danger  from  this  source  is  greatly  ex- 


aggerated;  however,  to  prevent  any  possible  danger  in  this  way  these 
methods  of  vaccination  have  been  practically  abandoned  and  the  method 
just  referred  to  has  been  substituted,  that  is,  the  virus  is  secured  from 
calves  in  the  manner  already  described. 

Those  who  are  practically  familiar  with  vaccination  recognize  that  it 
does  not  confer  immunity  or  protection  in  every  case;  still,  this  in  no 
way  alfects  the  inestimable  value  of  this  form  of  protection  for,  as  a 
rule,  it  can  be  depended  upon,  if  not  always  to  prevent  the  disease 
at  least  to  render  it  mild.  In  some  instances  the  primary  or  first 
vaccination  will  protect  throughout  life,  in  other  cases  it  may  not  insure 
immunity  for  more  than  two  or  three  years;  however,  it  is  believed  by 
those  who  are  competent  to  judge,  that  if  a person  is  successfully  vac- 
cinated in  infancy  and  again  about  ten  or  twelve  years  of  age,  immunity 
is  generally  conferred  throughout  life.  This  course  has  been  strictly 
followed  in  Germany  and  there  is  probably  no  country  where  fewer  cases 
of  Smallpox  occur;  however,  it  is  generally  believed  that  vaccination 
should  be  performed  every  seven  to  ten  years.  There  is  scientific  evidence 
to  support  this  view  and  it  should  be  regarded  as  an  extra  precaution, 
particularly  in  the  presence  of  an  outbreak  of  Smallpox. 

There  are  some  who  do  not  approve  of  vaccination,  chiefiy  among  those 
who  have  had  little  or  no  personal  experience  with  this  means  of  protec- 
tion, some  of  whom  it  is  alleged  not  only  deliberately  distort  statistics 
relative  to  this  subject  to  suit  their  purpose,  but  present  all  sorts  of 
theories  other  than  vaccination  to  account  for  the  decline  of  Smallpox. 
While  it  is  not  the  object  of  this  article  to  discuss  this  point,  it  may  be 
said  that  in  the  ranks  of  anti-vaccinationists  there  are  found  but  few, 
if  any,  of  the  leading  practical  sanitarians  of  the  day  who,  from  long 
personal  experience,  know  the  value  of  vaccination  as  a protection  against 
Smallpox. 

Vaccination  is  often  objected  to  on  the  ground  that  danger  may  follow 
its  use.  Unpleasant  results  rarely  occur ; when  they  do  it  is  usually  the 
result  of  carelessness  or  uncleanliness.  These  conditions  also  present 
themselves  in  instances  where  simple  wounds  are  not  properly  protected. 

For  various  reasons  vaccination,  although  a simple  operation,  should! 
be  performed  by  physicians  and  not  laymen,  except  in  instances  where 
emergencies  exist;  besides,  those  vaccinated  should  be  kept  under  pro- 
fessional observation  until  the  arm  heals  and  the  scab  falls  off.  This  is 
not  only  for  the  welfare  of  the  person  vaccinated,  but  also  to  determine 
if  the  vaccination  proves  successful. 

In  order  to  secure  successful  vaccination  it  is  exceedingly  important 
that  great  care  be  taken  in  the  production  of  the  lymph  or  virus.  Vac- 
cine matter  is  now  prepared  largely  by  state  and  municipal  laboratories, 
and  free  vaccination  is  generally  preformed.  This  insures  without 
expense  the  best  virus  and  most  effective  means  of  performing  the  oper- 


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ation.  Health  authorities  throughout  the  country  should  be  equipped  to 
offer  free  vaccination  in  order  that  it  may  be  properly  and  fully  carried 
out,  and  it  should  be  without  expense  to  the  individual,  for  it  is  a general 
protective  measure. 

A very  simple,  practical  and  sanitary  method  of  vaccination  which  is 
at  present  employed  consists  in  the  scarification  of  the  skin  with  the  point 
of  a needle  in  order  that  too  much  blood  may  not  be  drawn,  the  lymph 
being  transferred  from  the  vial  to  the  skin  by  wooden  tooth  picks,  both 
the  needle  and  picks  having  been  purchased  in  unopened  packages  and 
therefore  new  and  clean.  These  are  io  he  used  hut  once  and  then  thrown 
away. 

The  character  or  appearance  of  a successful  vaccination  depends  upon 
whether  or  not  it  is  a primary  or  a first  vaccination,  or  a secondary  or  re- 
vaccination. A primary  vaccination  may  easily  be  detected  by  a white 
pearly  ring  which  surrounds  the  vesicle  in  its  early  stage ; this  does  not 
appear  in  the  revaccination,  the  latter  having  no  special  characteristics, 
which  as  a rule  a layman  would  recognize.  It  is  to  properly  determine 
the  success  of  this  operation  that  the  observation  of  a physician  is  neces- 
sary for,  while  a revaccination  may  be  quite  sore  and  painful  and  asso- 
ciated with  considerable  inflammation,  it  does  not  necessarily  follow  that 
it  is  successful  or  confers  immunity;  this  is  decided  largely  by  the  ap- 
pearance of  the  scar.  Many  persons  vaccinate  themselves  or  members  of 
their  family,  or  after  having  been  vaccinated  by  a physician,  do  not  see 
him  again  in  order  that  the  result  of  the  operation  may  be  determined, 
and  therefore  cannot  be  sure  that  protection  is  conferred  and  may  be 
susceptible  to  Smallpox.  Therefore,  it  is  necessary  that  the  result  of 
every  vaccination  should  be  examined  by  a physician. 

The  outside  of  the  left  arm  is  usually  chosen  for  vaccination  for,  as 
a rule,  it  is  used  less  than  the  right  one,  and  therefore  subjected  to  less 
movement.  For  appearance  sake  some  are  vaccinated  on  the  leg,  al- 
though this  is  less  desirable.  The  local  symptoms  are  apt  to  be  more 
severe  and  locomotion  is  not  infrequently  interfered  with. 


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